GW1-2021-00499_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Hugo Rivas �4rwrRt►1vts fig= ,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
3159
ft. ft.
NC Well Contractor Certification Number
i5.4! RCrASII` dr""uiuTH casetl''" s E?Ry3NFaR s cab3e
Mcpherson Well Drilling FROM I TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft- 205 ft- 2 in sch40 pvc
>T6,Tfij1!i12° 1NC,(IRBTIVG: 'ehfherfiSatclosed-16n
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 205 ft 215 ft- 2 " 8 sch40 pvc
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft 205 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Uri ation ❑Wells> 100,000 GPD FROM TO MATERIALS EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fc. 3 ft. cement pour
❑Monitoring ❑Recovery 3 ft. 100 ft- bentonite tremmie
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
�-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 100 ft• 215 ft• gravel#1 pour
❑Experimental Technology ❑Subsidence Control
[]Geothermal(Closed Loop) ❑Tracer h2ti: X2T1tETi�IGiT13Y atfae4sddltio60`sltaetsStnecessh
N. _s
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock typS grain size,etc.)
0 ft. 40 rt. sand
4.Date Well(s)Completed: 10/22/21 Well ID# 40 ft. 120 ft' clay
5a.Well Location: 120 ft 135 ft' sand
Melton Moore 135 ft. 170 ft- clay
Facility/Owner Name Facility ID#(if applicable) 170 rL 180 ft- sand/clay DE t
3119 Old Northeast Rd Lake Waccamaw 28450 180 ft• 215 ft• sand
Physical Address,City,and Zip
Columbus
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Cer' anon:
N W
6.Is(are)the well(s): InPermanent or []Temporary Signature of C ificd VkV Contractor Date
By signing this form,I hereby certifi•that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l!lNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 21 5 (ft.)
For multiple wells list all depths ifdiJjerent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use'•+" Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Granular Amount: 1/8
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018